Commissural Malalignment of Aortic-Pulmonary Sinus in Complete Transposition of Great Arteries

Commissural Malalignment of Aortic-Pulmonary Sinus in Complete Transposition of Great Arteries Soo-Jin Kim, MD, Woong-Han Kim, MD, Cheong Lim, MD, Sam Se Oh, MD, and Yang-Min Kim, MD Departments of Pediatric Cardiology, Cardiac Surgery, and Radiology, Sejong Heart Institute, Pucheon-City, Korea Background. Translocation of the coronary artery to the neoaorta is essential in the arterial switch operation. The goal of this study is to investigate (1) the frequency of commissural malalignment in complete transposition of the great arteries, (2) the usefulness of echocardiography in diagnosis of commissural malalignment, and (3) the impact of commissural malalignment on surgery. Methods. We retrospectively reviewed the medical records of 28 patients with complete transposition of the great arteries who underwent an arterial switch operation from February 2000 to August 2001. Results. Commissural malalignment was expected preoperatively in 11 patients by echocardiography and was confirmed in 13 patients intraoperatively. Four patterns of commissural malalignment were present: (1) sinusfacing of the pulmonary valve, (2) sinus-facing of the aortic valve, (3) sinus-facing of both valves, and (4) bicuspid pulmonary valve (functionally sinus-facing). Two patterns of severity were present: major and minor. To avoid torsion and stretching of the coronary arteries during surgery, various methods were needed: more extensive dissection of the coronary artery, trap door incision, supracommissural or juxtacommissural transfer, both coronary transfer to the same sinus, tube reconstruction of the coronary artery, and neoaorta dextrorotation anastomosis. One patient who had severe commissural malalignment died during the operation, and the cause of death was probably stretching or torsion of the coronary artery. Conclusions. The recognition of malalignment of the facing sinus in transposition of the great arteries can be detected preoperatively by echocardiography. The surgical procedure of the arterial switch operation is influenced by the presence of commissural malalignment. Preoperative awareness of commissural malalignment seems to be helpful for surgeons to predict the need for an alternative operational procedure. (Ann Thorac Surg 2003;76:1906 10) 2003 by The Society of Thoracic Surgeons The most important part of the arterial switch procedure may be the successful translocation of the coronary arteries without producing either kinking or torsion. It is essential for the surgeon to recognize the origin and proximal course of the coronary arteries, the spatial relationship of the arterial trunks one to the other, and the morphology and function of the semilunar valves. It is often discovered that the commissure between coronary arterial sinuses is poorly aligned but this had not been elucidated in advance. The goal of this study is to investigate (1) the frequency of commissural malalignment of the aortic-pulmonary sinus in complete transposition of the great arteries (TGA), (2) the usefulness of echocardiography in preoperative detection of commissural malalignment, and (3) the impact of commissural malalignment on surgery. Patients and Methods We evaluated the facing of the semilunar sinuses and the alignment of the interostial commissure of the aortic and Accepted for publication June 6, 2003. Address reprint requests to Dr Soo-Jin Kim, Sejong Heart Institute, 91-121, Sosa-dong, Sosa-Ku Pucheon-city Kyunggi-do, Korea 422-711; e-mail: ksoojn@yahoo.co.kr. pulmonary valves by echocardiography, the mutual relationship of the orifices of the great arteries, the morphology of the semilunar valves, and the origin and course of the coronary arteries. Echocardiographic examination for evaluation of the semilunar valves was performed with classic views and especially with the en face view of both valves at high parasternal level (Fig 1). Twenty-eight patients with TGA who visited our institution between February 2000 and August 2001 and 13 (46%) patients who have commissural malalignment of two arterial valves were evaluated. All patients received the arterial switch operation. All operations were performed by the same surgeon (W.H.K.). Analysis of the alignment of the commissures was classified into four patterns by sinus-facing valve or rotation of the semilunar valve (Fig 2) and classified into two patterns by severity of commissural malalignment (Fig 3). Patterns by sinus-facing valve or rotation of the semilunar valve were sinus-facing of the pulmonary valve, sinus-facing of the aortic valve, sinus-facing of both valves, and bicuspid valve (functionally sinusfacing). We decided that the semilunar valve that the commissure is not in the line of crossing between the centers of both semilunar valves is a rotated or malposi- 2003 by The Society of Thoracic Surgeons 0003-4975/03/$30.00 Published by Elsevier Inc doi:10.1016/s0003-4975(03)01068-3

Ann Thorac Surg KIM ET AL 2003;76:1906 10 COMMISSURAL MALALIGNMENT IN TGA 1907 Fig 1. Echocardiographic view showing commissural malalignment (sinus-facing pattern of pulmonary valve [PV]). (AV aortic valve.) tioned valve. Patterns by severity of commissural malalignment were major and minor malalignment. Results Among the 13 commissural malalignment patients, there were 9 boys and 4 girls. Their ages ranged from 2 to 46 days (mean, 17.5 days), and the weight ranged from 2.8 to 5.1 kg (mean, 3.6 kg). Ten patients underwent surgery with echocardiography only and without cardiac catheterization and angiography. In the other 3 patients, catheterization and angiography for balloon atrial septostomy were performed. Commissural malalignment was detected preoperatively by echocardiography and confirmed intraoperatively in 11 patients. Commissural malalignment was detected at the operative field in the other 2 patients. Patterns by sinus-facing valve or rotation of the semilunar valve were sinus-facing of the pulmonary valve in 7 patients, sinus-facing of the aortic valve in 2 patients, sinus-facing of both valves in 2 patients, and bicuspid valve (functionally sinus-facing) in 2 patients. Patterns by Fig 3. Malalignment pattern according to severity of malalignment. (A) Minor (n 5). (B) Major (n 8). severity of commissural malalignment were 8 patients in major and 5 patients in minor malalignment. In the cases in which the interostial commissure is poorly aligned, we were faced with a dilemma of classifying the sinuses (Fig 4). In the presence of sinus-facing of the aortic valve, there were two nonfacing sinuses. Therefore, we could not decide the stance site of an observer looking toward the pulmonary trunk and leftfacing or right-facing sinus. We analyzed the position of the great arteries and the coronary arterial pattern in patients with commissural malalignment. Other positions of the great arteries except the right anterior aorta and complex coronary anat- Fig 2. Malalignment pattern according to sinus-facing valve or rotated valve. (A) Sinus-facing of the pulmonary valve (n 7). (B) Sinus-facing of the aortic valve (n 2). (C) Sinus-facing of both valves (n 2). (D) Bicuspid pulmonary valve (n 2).

1908 KIM ET AL Ann Thorac Surg COMMISSURAL MALALIGNMENT IN TGA 2003;76:1906 10 Table 2. Coronary Arterial Patterns in Patients With Commissural Malalignment Coronary Arterial Patterns Number of Patients (%) LAD, LCX from sinus 1, RCA from sinus 2 4/13 (31%) LAD from sinus 1, RCA, LCX from sinus 2 3/13 (25%) None from sinus 1, LAD, LCX, RCA from 4/13 (31%) sinus 2 Dual LAD 2/13 (15%) RCA, LAD from sinus 1, LCX, LAD 1 from sinus 2 LAD from sinus 1, RCA, LCX, LAD 1 from sinus 2 LCX left circum- LAD left anterior descending coronary artery; flex artery; RCA right coronary artery. Fig 4. Dilemma for classification of sinus. (L left; R right.) omy with abnormal courses may be frequent in TGA with commissural malalignment (Tables 1, 2). Other complexity factors of the arterial switch operation were marked discrepancy of the great arteries in 3 patients, single coronary arteries in 2 patients, side-byside relationship of the great arteries in 2 patients, and TGA with posterior aorta in 1 patient. All patients underwent the arterial switch operation. Because of the long distance for coronary transfer, many techniques were needed to avoid kinking or torsion of the coronary arteries. All patients required more extensive dissection of the coronary arteries than usual, and a trap door incision was required in 10 patients. Five patients underwent coronary transfer to a supracommissural or juxtacommissural site because of kinking or torsion of the coronary arteries. Four patients underwent transfer of two coronary artery systems to the same sinus also for the same reason. Also, tube reconstruction of the coronary artery was performed in 1 patient (Fig 5). In 1 patient, a neoaorta dextrorotation anastomosis was performed to avoid stretching of the coronary arteries. One patient died immediately after the arterial switch operation. He had a TGA with posterior aorta, severe commissural malalignment of the semilunar valves, and an unusual coronary artery pattern (right coronary artery Table 1. Great Arterial Patterns in Patients With Commissural Malalignment Great Arteries Patterns (AV relative to PV) Commissural Malalignment (%) Anterior and to the right 8/13 (53%) Side-by-side, aorta to right 2/13 (15%) Directly anterior 2/13 (15%) Posterior and to the right 1/13 (7%) AV aortic valve; PV pulmonary valve. and left anterior descending coronary artery from sinus 1, left circumflex artery and left anterior descending coronary artery from sinus 2; dual left anterior descending coronary arteries). After an uneventful surgical procedure, sudden cardiac arrest developed at the intensive care unit. The cause of death was suggested to be that during the postoperative period of the intensive care unit, the great arterial walls were stretched as intracardiac blood volume increased and the coronary artery was compressed. This probably resulted in coronary insufficiency and death. The other 12 patients are doing well and none has ventricular dysfunction or significant neoaortic regurgitation. Comment The arterial switch operation is now the established method of repair for complete transposition and related lesions. Unfavorable patterns of coronary arterial distribution may be the single most important risk factor for performing this procedure. The cause of most early deaths appears to be related to difficulties encountered during the transfer of the coronary arteries [1]. Many large series stress the importance of safe transfer of the coronary arteries as the essence of a good switch operation [2 8]. They further emphasize the pitfalls inherent in not recognizing the more complex coronary arterial patterns. The commissure of two semilunar valves was often not in line: this malalignment varied from a minor deviation of the commissure in relation to that of the opposite valve, to a position in which the commissure between the two facing sinuses of one valve was opposed to the middle of a sinus of the opposite valve. Analysis of the alignment of the commissure revealed four patterns and severity of malalignment. The previous reports revealed that the incidence of commissural malalignment is from 13% to 35%, and our report reveals that the incidence is relatively higher (46%) than the previous reports [9, 10]. Also, most of our cases (11 of 13 patients) could be detected preoperatively. In the report by Massoudy and colleagues [10], the malalignment was more frequent in side-by-side vessels.

Ann Thorac Surg KIM ET AL 2003;76:1906 10 COMMISSURAL MALALIGNMENT IN TGA 1909 Fig 5. Modification of surgical method for coronary transfer to avoid tension or torsion. (A) Transfer to the same sinus. (B) Tube reconstruction. (C) Supracommissural transfer. (D) Transfer to the same sinus in the bicuspid pulmonary valve. Also, other positions of the great arteries except the right anterior aorta and complex coronary anatomy with abnormal courses may be frequent in TGA with commissural malalignment in our cases. While studying the aortic semilunar sinuses, we encountered a problem with regard to the terminology in use for three aortic sinuses. Usually, in TGA the aortic sinuses are designated as right-facing sinus, left-facing sinus, and nonfacing sinus by the nomenclature of Anderson and Becker [11]. They were described as seen from the stance of an observer in the nonadjacent aortic sinus looking toward the pulmonary trunk. In two of our cases, it is confusing to use nomenclature for sinus-facing aortic valves (Fig 4). For example, in cases of sinus-facing aortic valve, there were two nonfacing sinuses, and we could not decide which was the right-facing or left-facing sinus. Uemura and colleagues [12] have discussed the significance of the bicuspid pulmonary valve (functionally sinus-facing) in the arterial switch procedure. They speculated that the direction of the commissure between the two leaflets of the initial pulmonary valve, at right angles to the commissure between the facing aortic leaflets, might have restricted the potential site of anastomosis between the coronary arterial buttons and the neoaorta. Commissural malalignment may not be an absolute risk factor, but in cases combined with abnormal coronary arterial course, it can be a high risk factor. Also, it requires various surgical techniques when coronary transfer is performed In conclusion, our reports reveal that commissural malalignment is often discovered in complete TGA, and it can be detected by preoperative echocardiography. Therefore, we suggest that this commissural malalignment should alert the surgeons to a potentially difficult reimplantation of the coronary arteries. It may also predicate the need for an alternative operative procedure. References 1. Kirklin JW. The surgical repair for complete transposition. Cardiol Young 1991;1:13 25. 2. Quagebeur JM, Rohmer J, Buis T, Kirklin JW, Blacstone EH, Brom AG. The arterial switch operation. An eight-year experience. J Thorac Cardiovasc Surg 1986;92:361 84. 3. Norwood W, Dobell A, Freed M, Kirklin JW, Blackstone E, and the Congenital Heart Surgeons Society. Intermediate results of the arterial switch repair. J Thorac Cardiovasc Surg 1988;96:854 63. 4. Castaneda AR, Norwood WI, Jonas RA, Colon SD, Sanders SP, Lang P. Transposition of the great arteries and intact ventricular septum: anatomical repair in the neonate. Ann Thorac Surg 1984;38:438 43. 5. Planche C, Bruniaux J, Lacour-Grayet F. Switch operation for transposition of the great arteries in neonates; a study of 120 patients. J Thorac Cardiovasc Surg 1988;96:354 63. 6. Day RW, Laks H, Drinkwater DC. The influence of coronary anatomy on the arterial switch operation in neonates. J Thorac Cardiovasc Surg 1992;104:706 12. 7. Yamaguchi M, Hosokawa Y, Imai Y, et al. Early and midterm results of the arterial switch operation for transposition

1910 KIM ET AL Ann Thorac Surg COMMISSURAL MALALIGNMENT IN TGA 2003;76:1906 10 of the great arteries in Japan. J Thorac Cardiovasc Surg 1990;100:261 9. 8. Mayer JE, Sanders SP, Jonas RA, Castaneda AR, Wernovsky G. Coronary artery pattern and outcome of the arterial switch operation for transposition of the great arteries. Circulation 1990;82(Suppl 4):IV-139 45. 9. Gittenberger DR, Ursula S, Arentje OD, Jan Q. Coronary arterial anatomy in transposition of the great arteries: a morphologic study. Pediatr Cardiol 1983;4(Suppl 1):15 24. 10. Massoudy P, Baltalarli A, de Leval MR, et al. Anatomic variability in coronary arterial distribution with regard to the arterial switch procedure. Ciculation 2002;106:1980 4. 11. Anderson RH, Becker AE. Coronary arterial patterns: a guide to identification of congenital heart disease. In: Becker AE, Losekoot G, Anderson RH, eds. Pediatric cardiology, 3rd ed. Edinburgh: Churchill Livingstone, 1981:251 62. 12. Uemura H, Yagihara T, Kawashima Y, et al. A bicuspid pulmonary valve is not a contraindication for the arterial switch operation. Ann Thorac Surg 1995;59:473 6. Notice From the American Board of Thoracic Surgery The 2004 Part I (written) examination will be held at the Sofitel O Hare Hotel, Rosemont, Chicago, IL, on November 21, 2004. The closing date for registration is August 1, 2004. Those wishing to be considered for examination must request an application because it is not automatically sent. To be admissible to the Part II (oral) examination, a candidate must have successfully completed the Part I (written) examination. A candidate applying for admission to the certifying examination must fulfill all the requirements of the Board in force at the time the application is received. Please address all communications to the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201; telephone: (847) 475-1520; fax: (847) 475-6240; e-mail: info@abts.org. 2003 by The Society of Thoracic Surgeons Ann Thorac Surg 2003;76:1910 0003-4975/03/$30.00 Published by Elsevier Inc